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L = Waste Tire S & Inspection Repor nspection Report Number <br /> "HiState of California 11 - 1088338 <br /> Cl ment Board 181(New04104) Survey Form - Page 1 <br /> California Integrated Waste Manage <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l O O / ® Routine Q Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �QC O CHP Q CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address — ' ` <br /> l 0 1 ���vu <br /> C+ � „�;3) <br /> Inspection Date � I <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ' 0 PM 0 PM <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active O Passenger O Generator O Outdoor <br /> 0 Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 ® Inactive Q Truck <br /> Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet O Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer (l ° *^o^' Crumb Rubber <br /> O Service Statior UNICIIN PACIFIC Other <at y Qy'd <br /> Part B - Ins e( C �� -Use Facility ENFORCEMENT STATUS <br /> p Y <br /> V j'A HAUU <br /> O O -- - - —PRC§, PATRICK L. BURRIS 0 Notice Of Violation Q Extension <br /> Q Q PRC§` �� Compliance Deadline <br /> O O PRC§4 (� •C l <br /> 0 0 14 CCR EAST ROTC ROAD ?nts Date m <br /> O O 14 CCR FRENCENC H CAMP,CA 95231 <br /> MANAGER INTERMODAL PH:(209)942-5279 <br /> 0 0 14 CCR OPERATIONS FAX:(209)942-5395 (Required for NOV or EXT) <br /> O O <br /> 14 CCR r<elentlon or t;omprehensive Trip Logs for 3 years <br /> O Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 1 O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance No Violations <br /> 0 0 Other: - <br /> Comments ' S' � `�,, <br /> Gt I y c�►'e� - C � f t� mev-s .. �1 'tD�`s; !3�(� 3 7 t 4 00 3 aeLd 13 Q 0 62-? <br /> UrilII Pact, C, CA Des r-►bt L� -+� Wa_s;t _ -hre-sT-4a.ctiva-'e IN) <br /> N , ri evJ _ Abn.t- No / i 0l a1*vn Is - <br /> Inspection Form Included: Q <br /> Comments Included: �B�N <br /> rAe-gs—_e Sign ture Phmber Inspector' ignature Phone Number <br /> - INSTRUCTIONS ON BACK � �ri � A� 4 P E p 3 62081 <br /> f <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />